INTRODUCTION

To define abnormal labor, a definition of normal labor must be understood and accepted.

Normal labor is defined as uterine contractions that result in progressive dilation and

effacement of the cervix. By following thousands of labors resulting in uncomplicated vaginal

deliveries, time limits and progress milestones have been identified that define normal labor.

Failure to meet these milestones defines abnormal labor, which suggests an increased risk of

an unfavorable outcome. Thus, abnormal labor alerts the obstetrician to consider alternative

methods for a successful delivery that minimize risks to both the mother and the infant.

Dystocia of labor is defined as difficult labor or abnormally slow progress of labor. Other terms

that are often used interchangeably with dystocia are dysfunctional labor, failure to progress

(lack of progressive cervical dilatation or lack of descent), and cephalopelvic disproportion

(CPD).

Labor happens in three stages and can actually begin weeks before you give birth:

The first stage starts once contractions begin and continues until you’re fully dilated, which

means being dilated 10 centimeters, or 4 inches. This means your cervix has opened completely

in preparation for childbirth. The second stage is the active stage, during which you begin to

push downward. It starts with complete dilation of the cervix and ends with the birth of your

baby. The third stage is also known as the placental stage. This stage begins with the birth of

your baby and ends with the completed delivery of the placenta.

Most pregnant women go through theses stages without experiencing any problems. Some

women, however, may experience abnormal labor during one of the three stages of labor.

DEFINITION

Abnormal labor may be referred to asdysfunctional labor, which simply means difficult labor

or childbirth. When labor slows down, it’s called protraction of labor. When labor stops

altogether, it’s called arrest of labor.

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TYPES OF ABNORMAL LABOR

The following types of abnormal labor may occur at any point during the three stages of labor:

❖ Uterine hypocontractility

This type of abnormal labor is usually referred to as uterine inertia or uterine hypocontractility.

Labor may start out well but stop or stall later if the uterus fails to contract sufficiently.

Medications that lessen the intensity or frequency of the contractions can sometimes cause it.

Uterine hypocontractility is most common in women going through labor for the first time.

Doctors usually treat the condition with oxytocin to augment labor.

❖ Cephalopelvic disproportion

If labor is still slow or stalled after your doctor gives you oxytocin, your baby’s head may be

too large to fit through your pelvis. This condition is commonly called cephalopelvic

disproportion (CPD).

Unlike uterine hypocontractility, CPD can’t be corrected with oxytocin, so labor can’t progress

normally after treatment. As a result, women who experience CPD give birth by cesarean

delivery. Cesarean delivery happens through an incision in the abdominal wall and uterus rather

than through the vagina. CPD is very rare. According to the American Pregnancy Association,

CPD only occurs in approximately one of every 250 pregnancies.

❖ Macrosomia

Macrosomia occurs when a newborn is much larger than average. A newborn is diagnosed with

macrosomia if they weigh more than 8 pounds, 13 ounces, regardless of when they’re born.

Approximately 9 percent of babies born worldwide have macrosomia.

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This condition can cause problems during childbirth that can sometimes result in injury. It also

puts the baby at an increased risk for health problems after birth. There are more risks to the

mother and baby when a baby’s birth weight is greater than 9 pounds, 15 ounces.

❖ Precipitous labor

On average, the three stages of labor last about six to 18 hours. With precipitous labor, these

stages progress much more quickly, lasting only three to five hours. Precipitous labor, also

called rapid labor, may occur for several reasons:

• Your uterus is contracting very strongly, helping to push the baby out more rapidly.

• Your birth canal is compliant, making it easier for the baby to leave the womb.

• You have a history of precipitous labor.

• Your baby is smaller than average.

Precipitous labor presents several risks for the mother. These include vaginal or cervical

tearing, heavy bleeding, and shock following birth. Precipitous labor may also make the baby

more susceptible to infection if they’re born in an unsterile environment, such as a car or

bathroom.

❖ Shoulder dystocia

Shoulder dystocia occurs when the baby’s head is delivered through the mother’s vagina, but

their shoulders get stuck inside the mother’s body. This usually isn’t discovered until labor has

begun, so there’s no way to predict or prevent it.

Shoulder dystocia can pose some risks for both you and your baby. You may develop certain

injuries, including excessive bleeding and tearing of the vagina, cervix, or rectum. the baby

might experience nerve damage and a lack of oxygen to the brain. In most cases, however,

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babies are delivered safely. Doctors are usually able to ease the baby out by applying pressure

to the mother’s lower belly or by turning the baby’s shoulder.

❖ Uterine rupture

A uterine rupture is a tear in the wall of the uterus, usually at the site of a previous incision.

This condition is rare, but it’s most often seen in women who’ve had uterine surgery or who

have previously given birth by cesarean delivery.

When a uterine rupture occurs, an emergency cesarean delivery is necessary to prevent serious

problems for you and your child. Potential problems include brain damage in the baby and

heavy bleeding in the mother. In some cases, removal of the uterus, or a hysterectomy, is

necessary to stop the mother’s bleeding. However, doctors can repair most uterine tears without

any issues. Women with certain types of uterine scars should give birth via cesarean delivery

rather than vaginally to avoid uterine rupture.

❖ Umbilical cord prolapse

Umbilical cord prolapse occurs when the umbilical cord slips out of the cervix and into the

vagina ahead of the baby. This most often happens during labor, particularly as a result of

the premature rupture of membranes. Umbilical cord prolapse can lead to umbilical cord

compression, or increased pressure on the umbilical cord.

While in the womb, babies occasionally experience mild, short-term umbilical cord

compressions, which are harmless. In some cases, however, these compressions can become

more severe and last for longer periods. Such compressions can result in a decreased flow of

oxygen to the baby, lowering their heart rate and blood pressure. These problems may lead to

serious complications to the baby, including brain damage and delayed development. To help

prevent these problems, doctors usually move the baby away from the umbilical cord or deliver

the baby immediately by cesarean delivery.

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 ❖ Retained placenta

The placenta is the organ that forms in the uterus and attaches to the uterine wall during

pregnancy. It provides your baby with nutrients and removes wastes created by your baby’s

blood. After the baby is delivered, the mother normally delivers her placenta through her

vagina. However, if the placenta remains in the womb for more than 30 minutes after childbirth,

it’s considered a retained placenta.

Retained placenta can occur when your placenta becomes caught behind your cervix or when

your placenta remains attached to the uterine wall. If it’s left untreated, retained placenta can

cause complications, including a severe infection or blood loss.

❖ Postpartum hemorrhage

Postpartum hemorrhage occurs when there’s excessive bleeding following childbirth, usually

after delivery of the placenta. While a woman will usually lose about 500 milliliters of blood

after childbirth, a postpartum hemorrhage will cause a woman to lose nearly double that

amount. The condition is most likely to occur after birth by cesarean delivery. It may happen if

an organ is cut or if your doctor doesn’t stitch the blood vessels properly.

Postpartum hemorrhage can be very dangerous for the mother. Too much blood loss can cause

a steep drop in blood pressure, leading to severe shock if left untreated. In most cases, doctors

give blood transfusions to women experiencing postpartum hemorrhage to replace lost blood.

❖ The bottom line

Childbirth is a very complex process. It’s possible for complications to occur. Abnormal labor

may affect some women, but it’s fairly rare. Talk to your doctor if you have any questions or

concerns about your risk for abnormal labor.

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PATHOPHYSIOLOGY

In general, abnormal labor is the result of problems with one of the following three P' s:

• Passenger (infant size, fetal presentation [occiput anterior, posterior, or transverse])

• Pelvis or passage (size, shape, and adequacy of the pelvis)

• Power (uterine contractility)

A prolonged latent phase may result from oversedation or from entering labor early with a

thickened or uneffaced cervix. It may be misdiagnosed in the face of frequent prodromal

contractions. Protraction of active labor is more easily diagnosed and is dependent upon the

3 P' s.

The first P, the passenger, may produce abnormal labor because of the infant's size

(eg, macrosomia) or from malpresentation.

The second P, the pelvis, can cause abnormal labor because its contours may be too small or

narrow to allow passage of the infant. Both the passenger and pelvis cause abnormal labor by

a mechanical obstruction, referred to as mechanical dystocia.

With the third P, the power component, the frequency of uterine contraction may be adequate,

but the intensity may be inadequate. Disruption of communication between adjacent segments

of the uterus may also exist, resulting from surgical scarring, fibroids, or other conduction

disruption. Whatever the cause, the contraction pattern fails to result in cervical effacement and

dilation. This is called functional dystocia. Uterine contractile force can be quantified by the

use of an intra-uterine pressure catheter. Use of this device allows for direct measurement and

calculation of uterine contractility per each contraction and is reported in Montevideo units

(MVUs). For uterine contractile force to be considered adequate, the force produced must

exceed 200 MVUs during a 10-minute contraction period. Arrest disorders cannot be properly

diagnosed until the patient is in the active phase and had no cervical change for 2 or more hours

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with the contraction pattern exceeding 200 MVUs. Uterine contractions must be considered

adequate to correctly diagnose arrest of dilation.

PATIENT EDUCATION

The patient must be aware of all risks involved with labor, including the potential for emergent

cesarean delivery if the fetus appears compromised. Furthermore, she should be kept informed

of her status throughout the labor course, especially if a change in management is anticipated.

Counsel patients early in pregnancy that maternal weight gain correlates with fetal weight gain,

and excessive gain and prepregnancy obesity are risk factors for abnormal labor.

ABNORMAL LABOR TREATMENT & MANAGEMENT

Medical Care

A prolonged latent phase (see Table in Background) is not indicative of dystocia in itself

because this diagnosis cannot be made in the latent phase. Gabbe and colleagues state the

following:

For those in the latent phase, the treatment of choice is rest for several hours. During this

interval, uterine activity, fetal status, and cervical effacement must be evaluated to determine

if progress to the active phase has occurred. Approximately 85% of patients so treated progress

to the active phase. Approximately 10% will cease to have contractions, and the diagnosis of

false labor may be made. For the approximately 5% of patients in whom therapeutic rest fails

and in patients for whom expeditious delivery is indicated, oxytocin infusion may be used.

Use of oxytocin for active management of labor is described in the Medication section.

Limited studies have shown improvement in dysfunctional labor with use of a beta-blocker. In

cases of dysfunctional labor resulting from functional dystocia or an abnormal uterine

contractility pattern and in which oxytocin implementation has not improved the outcome, a

beta-blocker may be considered. Low-dose administration of intravenous propranolol in

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abnormal labor augmented with oxytocin reduced the need for cesarean delivery, particularly

among patients with inadequate uterine contractility.

Anecdotal reports have stated that simply repositioning the patient frequently relieves a

seemingly obstructed labor. Although not studied rigorously, there appears to be little harm in

this maneuver. In theory, it may unseat an asynclitic or malrotated presenting part and allow it

to engage in the pelvis more effectively.

Some studies looked at the use of the “peanut ball”, which is an exercise ball shaped like a

peanut, and found that use of it during labor significantly decreased the length of first stage of

labor in nulliparous women. Another study on the same topic found that both first and second

stages of labor were shortened by 29 min and 11 min respectively, and cesarean delivery rate

was significantly reduced. Overall, given the low risk of such intervention, it appears to be

worth trying in prolonged labor, particularly in nulliparous women.

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CONCLUSION

Abnormal labor presents a complex challenge during childbirth, requiring careful monitoring

and intervention to ensure the safety of both mother and baby. Recognizing the signs of

abnormal labor early and implementing appropriate medical interventions can help mitigate

risks and facilitate a successful delivery. However, it's essential to approach each case

individually, considering the unique circumstances of the mother and baby, and to maintain

open communication between the medical team and the expectant parents throughout the labor

process. By working together, healthcare providers and families can navigate abnormal labor

effectively, ultimately achieving the goal of a healthy outcome for both mother and child.

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